Abstract

Problem/Condition: CDC began abortion surveillance in 1969 to document the number and
characteristics of women obtaining legal induced abortions.

Reporting Period Covered: This report summarizes and describes data voluntarily reported to CDC
regarding legal induced abortions obtained in the United States in 2004.

Description of System: For each year since 1969, CDC has compiled abortion data by state or area
of occurrence. During 1973--1997, data were received from or estimated for 52 reporting areas in the
United States: 50 states, the District of Columbia, and New York City. In 1998 and 1999, CDC compiled
abortion data from 48 reporting areas. Alaska, California, New Hampshire, and Oklahoma did not report, and data
for these states were not estimated. During 2000--2002, Oklahoma again reported these data, increasing
the number of reporting areas to 49; for 2003 and 2004, Alaska again reported and West Virginia did
not, maintaining the number of reporting areas at 49.

Results: A total of 839,226 legal induced abortions were reported to CDC for 2004 from 49 reporting
areas, representing a 1.1% decline from the 848,163 legal induced abortions reported by 49 reporting areas
for 2003. The abortion ratio, defined as the number of abortions per 1,000 live births, was 238 in 2004,
a decrease from the 241 in 2003. The abortion rate was 16 per 1,000 women aged 15--44 years for 2004,
the same since 2000. For the same 47 reporting areas, the abortion rate remained relatively constant during
1998--2004. In 2003 (the most recent years for which data are available), 10 women died as a result
of complications from known legal induced abortion. No death was associated with known illegal abortion.

The highest percentages of reported abortions were for women who were known to be unmarried (80%),
white (53%), and aged <25 years (50%). Of all abortions for which gestational age was reported, 61%
were performed at <8 weeks' gestation and 88% at <13 weeks. From 1992 (when detailed data regarding
early abortions were first collected) through 2004, steady increases have occurred in the percentage of
abortions performed at <6 weeks' gestation, except for a slight decline in 2003. A limited number of abortions
were obtained at >15 weeks' gestation, including 4.0% at 16--20 weeks and 1.4% at
>21 weeks. A total of 35 reporting areas submitted data stating that they performed and enumerated medical (nonsurgical)
procedures, making up 9.7% of all known reported procedures from the 45 areas with adequate reporting on type
of procedure.

Interpretation: During 1990--1997, the number of legal induced abortions gradually declined. When
the same 47 reporting areas are compared, the number of abortions decreased during 1996--2001, then
slightly increased in 2002 and again decreased in 2003 and 2004. In 2000 and 2001, even with one
additional reporting state, the number of abortions declined slightly, with a minimal increase in 2002 and a
further decrease in both 2003 and 2004. In 2003, as in the previous years, deaths related to legal induced
abortions occurred rarely.

Public Health Action: Abortion surveillance in the United States continues to provide the data necessary
for examining trends in numbers and characteristics of women who obtain legal induced abortions and to
increase
understanding of this pregnancy outcome. Policymakers and program planners use these data to improve
the health and well-being of women and infants.

Introduction

CDC began conducting abortion surveillance in 1969 to document the number and characteristics of
women obtaining legal induced abortions. This report is based on abortion data for 2004, provided voluntarily to
CDC's National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Division of Reproductive Health.

Methods

For 2004, CDC compiled data that were voluntarily provided from 49 reporting areas in the United States: 47
states (excluding California, New Hampshire, and West Virginia), the District of Columbia (DC), and New York City
(NYC). Legal induced abortion was defined as a procedure, performed by a licensed physician or someone acting under
the supervision of a licensed physician, that was intended to terminate a suspected or known intrauterine pregnancy and
to produce a nonviable fetus at any gestational age
(1,2). The total number of legal induced abortions was available from
all reporting areas; however, not all areas collected data on some or all characteristics of women who obtained abortions,
and the availability of such data varied by reporting
area.

Data on the age of women who obtained abortions were collected and reported adequately (i.e., categorized
in accordance with surveillance variables and with <15%
unknown values) by 48 reporting areas (46 states
[excluding California, Florida, New Hampshire, and West
Virginia], DC, and NYC), representing 88% of all reported
procedures. Data on ethnicity were collected and reported
adequately by only 27 reporting areas, representing 57% of all
reported procedures. The findings in this report reflect
characteristics of women only from reporting areas that
submitted adequate data for the characteristics being examined. For the majority of state tables, the percentage data include
a category for unknown values, and the percentage known to be in each category might be a slight understatement of
the true percentage in that category because of missing information. However, for trend data,
out-of-area residents, adolescent ages, and
two-characteristics tables, percentages presented are based on known values only.

For the 49 reporting areas, data on the number of women obtaining legal induced abortions were provided by
the central health agency.* These agencies provided data on numbers of abortions and characteristics of women
obtaining abortions by the reporting area in which the abortion was performed (i.e., state of occurrence). For the majority
of reporting areas, abortion totals also were available by the woman's state or area of residence. However, three
states (Delaware, Maryland, and Wisconsin) reported characteristics only for residents who obtained abortions in the state
but not for women from out-of-state. Three states (Florida, Kentucky, and Louisiana) did not report abortion totals
by resident status, and four states (Alaska, Arizona, Iowa, and Massachusetts) provided only the total number of
abortions for out-of-state residents without specifying individual states or areas of residence.

This report provides overall and state-specific abortion statistics. For all characteristics for which birth or
population data were available, abortion ratios (number of abortions per 1,000 live births) or abortion rates (number of
abortions per 1,000 women in a given age group) are provided. Beginning with 1996 data, abortion ratios were calculated
by using the number of live births to residents of each area from birth data reported to CDC's National Center for
Health Statistics (NCHS); these numbers were previously received from state health departments. The population data used
for calculating most recent abortion rates were obtained from the U.S. Census Bureau postcensual data
(3).

Women aged 20--39 years who obtained legal induced abortions were categorized by 5-year age groups,
adolescents aged 15--19 years were categorized by single years of age, and the relatively few abortions at age <15 years or
>40 years each had one group. Abortion numbers, ratios, and rates are presented by age group. Because 94% of abortions
among adolescents aged <15 years occurred among those aged 13--14 years in 1988 (the latest year for which this
information is known) (4), the population of adolescents aged 13--14 years was used as the denominator for calculating
abortion rates for adolescents aged <15 years. Rates for women aged
>40 years were based on the number of women aged
40--44 years. However, rates for all females who obtained abortions were based on the population of females aged 15--44 years.

Race was categorized by three groups: white, black, and all other races. Other races included Asian or Pacific
Islander, American Indian, Alaska Native, and women classified as "other" race. Ethnicity was categorized as either Hispanic
or non-Hispanic. As in previous reports, race and ethnicity were provided as separate variables, and abortions were
not cross-classified by race and ethnicity. Abortion numbers, ratios, and rates are presented by both race and ethnicity.

Despite efforts to collect and provide a
cross-classification of race and ethnicity for the 2001 report in compliance
with OMB Directive 15, which specifies federal standards for the collection of data on race and ethnicity
(5), only 28 states (accounting for 39% of the total number of reported abortions) were able to provide adequate data for use of
the recommended race categories. Eleven states could not
adequately break down the data by ethnicity. Moreover,
three recommended racial categories (Asian, Native Hawaiian
or other Pacific Islander, and American Indian or Alaskan
Native) had to be combined into one category of "other" to accommodate overlapping categories provided by multiple states.
For these reasons, no additional information regarding race or ethnicity was obtained as a result of unavailable
data. Therefore, further efforts to collect cross-classified race and ethnicity will not be attempted unless additional states
start collecting such data.

Marital status was reported as either married (including women who were married or separated) or
unmarried (including those who were never married, widowed, or
divorced). Abortion numbers and ratios are presented by
marital status.

Gestational age (in weeks) at the time of abortion was
categorized as <6, 7, 8 and <8, 9--10, 11--12, 13--15,
16--20, and >21. Weeks of gestation were estimated in 11 reporting areas as the time elapsed since the woman's most
recent menstrual period. For 27 other states, gestational age was reported on the basis of the physician's estimate (data from
the clinical examination, including ultrasound results). For the remaining six states, gestational age was derived from
a combination of the physician's estimates and the time elapsed since the woman's most recent menstrual period. Of
the 44 areas that reported adequate data on weeks of gestation at the time of abortion, 41 also reported abortions
performed at <8 weeks' gestation separately for those performed at
<6, 7, and 8 weeks' gestation. Abortion numbers
are presented by gestational age.

The type of abortion procedure was categorized as curettage (including suction and/or sharp curettage at
any gestational age) and reported separately for
<12 weeks and >12 weeks, intrauterine instillation, medical
(nonsurgical) abortion (methotrexate and misoprostol or mifepristone and misoprostol were reported for abortions performed
at <8 weeks gestation; vaginal prostaglandins were primarily reported for abortions performed at later weeks of
gestation), and procedures described as other (including
hysterectomy and hysterotomy).

CDC has reported data on abortion-related deaths periodically since these deaths were first included in the
Abortion Surveillance Report in 1972 (6,7). An abortion-related death was defined as a death resulting from a direct
complication of an abortion, an indirect complication caused by the chain of events initiated by abortion, or aggravation of
a preexisting condition by the physiologic or psychologic effects of the abortion
(1,2). All deaths causally related to induced abortion are classified as induced
abortion-related regardless of the duration of time between the abortion
and the death.

Sources of data for abortion-related deaths included
national and state vital records, maternal mortality
review committees, surveys, private citizens and groups, media reports, health-care providers, medical examiners' reports,
public health agencies, and computerized searches of full-text newspaper/print media databases. For each death possibly
related to an induced abortion or an abortion of unknown type, clinical records and autopsy reports were requested
and reviewed by two clinically experienced medical epidemiologists to determine the cause of death and whether the
death was abortion related. Each abortion-related death was then categorized by abortion type as
legal induced, illegal induced, spontaneous, or unknown type. Data on abortion-related deaths for 1972--2003 are provided in this
report. The 2003 data have not been published previously and are the most recent data available. National case-fatality
rates were calculated as the number of known legal induced abortion-related deaths per 100,000 reported legal
induced abortions. Case fatality rates for 1972--1997 are provided in this report. Case fatality rates for 1998--2003 cannot
be calculated because a substantial number of abortions occur in the nonreporting states; as a result, the total number
of abortions (the denominator) is unknown.

Results

Overall, the annual number of legal induced abortions in the United States increased gradually from 1973 until
it peaked in 1990, and it generally declined thereafter
(Figure 1). In 2004, a total of 839,226 legal induced
abortions were reported to CDC by 49 reporting areas. This change represents a 1.1% decline from 2003, for which 49
areas reported 848,163 legal induced abortions (Tables 1 and
2).

The national legal induced abortion ratio increased from 196 per 1,000 live births in 1973 (the first year that 52
areas reported) to 358 per 1,000 in 1979 and remained nearly stable through 1981 (Figure 1; Table 2). The ratio peaked
at 364 per 1,000 in 1984 and since then has demonstrated a generally steady decline. In 2004, the abortion ratio was
238 per 1,000 in 49 reporting areas and 239 for the same 47 reporting areas for which data were available since 1998
(Table 2).

The national legal induced abortion rate increased from 14 per 1,000 women aged 15--44 years in 1973 to 25
per 1,000 in 1980. The rate remained stable, at 23--24 per 1,000 during the 1980s and early 1990s and at 20--21
per 1,000 during 1994--1997. The abortion rate remained unchanged at 17 per 1,000 during 1998--1999 and at 16
per 1,000 during 2000--2002 both overall and in the same 47 reporting areas. During 2003--2004, the abortion
rate remained unchanged overall at 16 per 1,000, decreased to 15 per 1,000 in 2003, and to 16 in 2004 in the
47 reporting areas.

The numbers, ratios, and rates of reported legal induced abortions are presented by area of residence and by area
of occurrence (Table 3). In 2004, the highest number of
reported legal induced abortions occurred in Florida
(91,710), NYC (91,673), and Texas (74,801); the
fewest occurred in Wyoming (12), South Dakota (814), and Idaho
(963) (Table 3). The abortion ratios by state or area of
occurrence ranged from 43 per 1,000 live births in Idaho to 770
per 1,000 in NYC. Among women aged 15--44 years, rates by occurrence ranged from three per 1,000 women in Idaho
to 30 per 1,000 in New York. These ratios and rates should be viewed with consideration of the sizable variation by state
in the percentage of abortions obtained by out-of-state residents. In 2004, approximately 8% of reported abortions
were obtained by out-of-state residents (range: from 0.2% [in Alaska] to 53% [in DC]) (Table 3). Data by state of
residence are incomplete because three states (California, New Hampshire, and West Virginia) did not report any data
on abortion, and seven states (Alaska, Arizona, Florida, Iowa, Kentucky, Louisiana, and Massachusetts) did not provide
data concerning the residence status of all women obtaining abortions in their state. Thus, ratios and rates by state
of residence should be viewed with caution because of the substantial variation in completeness of reporting of
residence information.

Women known to be aged 20--24 years obtained 33% of all abortions for which age was adequately
reported. Adolescents reported as age <15 years obtained <1.0% of all abortions in the 48 areas that reported age. Among the
48 reporting areas, age was not reported for 0.5% of patients; however, this percentage ranged from 0.0% (in 18 areas)
to 4.5% (Nevada) (Table 4). Abortion ratios were highest for adolescents aged <15 years (762 per 1,000 live births)
and lowest for women aged 30--34 years (143 per 1,000) (Figure 2; Table 4). In contrast to abortion ratios, among
females for whom age was reported, abortion rates were highest for women aged 20--24 years (30 per 1,000 women) and
lowest for females at the extremes of reproductive age (1 per 1,000 adolescents aged 13--14 years and 3 per 1,000 women
aged >40 years) (Table 4). Among women aged <20 years (46 reporting areas), the percentage of abortions obtained
increased with age (Table 5); however, the abortion ratio was highest for adolescents aged <15
years§ (773 per 1,000 live births) and lowest for women aged 19 years (325 per 1,000). Conversely, the rates of abortions were lowest (1 per 1,000)
for adolescents aged <15 years and highest (27 per 1,000) for women aged 19 years
(Table 5).

Abortion trends by age indicate that since 1973, abortion ratios have been higher for adolescents aged <15 years
than for any other age group (Figure 3). For females aged
<19 years and those aged >40 years, the abortion ratio
generally increased from 1974 through the early 1980s and declined thereafter. The abortion ratio for women aged 20--34
years (those with the highest fertility rates) has declined slightly since the mid-1980s. The abortion ratio for women aged
35--39 years has declined gradually over time (Figure 3).

In 2004, for women from areas where weeks of gestation at the time of abortion were adequately reported
(44 reporting areas), 61% of reported legal induced abortions were known to have been obtained at
<8 weeks' gestation and 87% at
<12 weeks (Table 6). Overall (41 reporting areas), 28% of abortions were known to have been performed at
<6
weeks' gestation, 18% at 7 weeks, and 15% at 8 weeks (Table 7). Few reported abortions were known to have
occurred after 15 weeks' gestation: 3.7% at 16--20 weeks and 1.3% at
>21 weeks.

For women whose type of procedure was adequately
reported, 87% of abortions were known to have been
performed by curettage (which includes dilatation and evacuation [D&E]) and 0.6% by intrauterine instillation
(Table 8). A total of 35 reporting areas submitted information regarding performance of medical (nonsurgical)
procedures¶ (hereafter referred to as medical abortion). Known medical abortions make up approximately 10% of all procedures reported
from the 45 areas with adequate reporting on type of procedure. In addition, two areas that did not collect data separately
for medical abortions on their abortion reporting form included medical abortions in the "other" category. For the 35
areas that reported medical abortions separately, 66,033 medical abortion procedures were performed in 2004. Eight
states reported that no medical abortions were performed in 2004 but did not specify whether such abortions were
available. For the 32 reporting areas that reported one or more medical abortion for both 2003 and 2004, the data reflect
an increase of 17%, from 54,703 in 2003 to 63,975 in 2004
(8). The extent to which the 66,033 medical
abortions reported to CDC for 2004 represent the use of this procedure in all reporting areas is unknown. Hysterectomy
and hysterotomy were included in the "other" procedure category and were used in <0.01% of all abortions.

In the 38 reporting areas for which race was provided, classified according to the same categories used in
previous years, approximately 53% of women who obtained legal induced abortions were white; 35%, black; and 8%, other;
race was not known for 4% (Table 9). The abortion ratio for black women (472 per 1,000 live births) was 2.9 times the
ratio for white women (161 per 1,000), and the ratio for women of the nonhomogeneous "other" race category (330
per 1,000) was 2.0 times the ratio for white women. The abortion rate for black women (28 per 1,000 women) was
2.9 times the rate for white women (10 per 1,000), and the abortion rate for women of other races (22 per 1,000
women) was 2.2 times the rate for white women.

A total of 27 reporting areas had separate and adequate
data** on the ethnicity of women who obtained
legal induced abortions (Table 10). The percentage of abortions known to have been obtained by Hispanic women in
these reporting areas was 19% overall (range: from 0.6% [in Mississippi] to 50% [in New
Mexico]).For Hispanic women in these reporting areas, the abortion ratio was 211 per 1,000 live births, and the abortion rate was 26 per 1,000
women. However, only 46% of Hispanic women in the United States resided in these reporting areas.

Because reporting areas provide data voluntarily, they are not required to use the 31 race/ethnicity
categories mandated by the Office of Management and Budget (OMB) for federally funded data collection. Although
providing data cross-classified by race and ethnicity would be helpful, collecting these data will not be continued unless
a substantial number of states change their race/ethnicity questions in this direction.

For women whose marital status was adequately reported (41 reporting areas), 80% of women who
obtained abortions were known to be unmarried (Table 11). The abortion ratio for unmarried women (510 per 1,000 live
births) was 8.4 times that for married women (61 per 1,000).

For women who obtained legal induced abortions and for whom data on previous live births were
adequately reported (41 reporting areas), 40% were known to have had no previous live births, and 32% had had two or
more previous live births (Table 12). The abortion ratio was highest for women who had
threeprevious live births (274 per 1,000 live births) and lowest for those who had one previous live birth (190 per 1,000).

For women who obtained an abortion and whose number of previous abortions were adequately reported
(41 reporting areas), 54% were reported to have obtained an abortion for the first time, and 19% were reported to have
had at least two previous abortions (Table 13).

For women whose age and race were known (36 reporting areas), the differences in age distributions of white and
black women were relatively small. White women had a slightly higher percentage of abortions in the youngest
(<19 years) and oldest (>35 years) age groups compared with black women (17.3% versus 16.9% and 12.5% versus
10.0%, respectively), whereas women of other races who had abortions tended to be older (Table 14). For women whose
marital status and race were both known (32 reporting
areas), the percentage of reported abortions among black women
who were unmarried was higher (89%) than that among white women (81%) or among women of other races
(64%). Among older (aged >35 years) women obtaining
abortions whose age and ethnicity were known and reported
adequately (26 reporting areas), the percentage of abortions obtained by non-Hispanic women (12%) exceeded that for
Hispanic women (10%) (Table 15). Among women whose marital status and ethnicity were known and reported adequately
(25
reporting areas), the percentage of reported abortions obtained by unmarried women was slightly higher for
non-Hispanic women (83%) than for Hispanic women (82%) (Table 15).

Approximately 88% of all abortions for which gestational age at the time of abortion was known and
reported adequately (44 reporting areas) were obtained at
<12 weeks' gestation (Table 1). The percentage of women who
obtained an abortion at <8 weeks' gestation increased with age
(Figure 4; Table 16). This association was most pronounced
for abortions obtained at <6 weeks' gestation (41 reporting areas) (Table 17). The percentage of women who obtained
an abortion decreased with age for women who obtained an abortion at 9--10, 11--12, and 13--15 weeks'
gestation, through age 30--34 years at 16--20 weeks' gestation, and through age 25--29 years at
>21 weeks' gestation (Table 16). Among women with adequately reported race and weeks of gestation (33 reporting areas), white women and women
of other races were more likely than black women to obtain abortions at
<6 and 7 weeks' gestation, but less likely after
that (Tables 16 and 17). Among women with adequately reported known ethnicity and weeks of gestation
(25 reporting areas), the difference in timing of their abortions between Hispanic and non-Hispanic women was
minimal (<4.3%) at any gestational age (Tables 16 and
17).

For women whose type of procedure and weeks of gestation were known and adequately reported (40 reporting
areas), approximately 89% of reported abortions obtained at
<15 weeks' gestation were performed by using curettage
(primarily suction procedures) (Table 18). Approximately 93% of the 68,099 reported medical abortions were performed at
<8 weeks' gestation, representing 14.2% of all abortions performed at
<8 weeks' gestation. At >16 weeks' gestation,
medical abortions (n = 888) made up 2.2% of all abortions. Medical abortions constituted 1.5% of procedures performed in
the 9--15 weeks' gestation range. Intrauterine instillation involving use of saline or prostaglandin was used rarely (0.1%
of all abortions), primarily at <8 weeks or at
>16 weeks' gestation.

From the National Pregnancy Mortality Surveillance System, CDC identified 26 deaths for 2003 that were thought
to be potentially related to abortion. These deaths were identified either by some indication of abortion on the
death certificate, from health-care providers, or from information such as a news or public health report associated with
the death. Investigation of the 2003 cases revealed that 10 of the 26 deaths were related to legal induced abortion and
none to illegal induced abortion (Table 19). Four of the 10 legal induced abortion-related deaths occurred following a
medical (nonsurgical) abortion procedure. Ten deaths were related to spontaneous abortion, and four deaths were found not
to be abortion related. The remaining three deaths were found to be not pregnancy related. Numbers of deaths
related to legal induced abortion were highest before the 1980s, with few deaths occurring in 2003.
Possible abortion-related deaths that occurred during 2004--2007 are being investigated.

Discussion

A total of 839,226 legal induced abortions were reported in the United States for 2004 from 47 states, DC, and
NYC, reflecting a decline of 1.1% from the number of
legal induced abortions reported for 2003. After five previous
annual decreases, a slight increase of 0.1% in the
number of abortions occurred in 2002, with another
decline of 0.7% in 2003 and a further decline of 1.1% in 2004. This pattern also is apparent when the same 47
reporting areas that reported for all years, 1998--2004, are compared with those that reported for 2001--2004
(Table 2). Before 1998, a substantial number of legal
induced abortions were estimated to have been performed in California (e.g., >23% of the U.S. total
in 1997) (9). The lack of data for California for 2004 largely explains the majority of the 28% decrease from the
annual number of abortions reported for 1997
(9) and part of the decrease in the total ratio and rate.

Overall, abortion ratios and rates have declined over time until 2002 (Figure 1). The abortion ratio for 2004 (238
per 1,000 live births for 49 reporting areas) decreased from the previous year (241). For the same reporting areas as
2000--2002, the abortion rate for women aged 15--44 years (16 per 1,000 women) remained identical to the
rate reported since 2000, then was 15 per 1,000 women for 2003 and 16 for 2004 (Table 2). The overall declines in
the abortion ratio and rate over time might reflect multiple factors, including a decrease in the number of
unintended pregnancies (10); a shift in the age distribution of women toward the older and less fertile ages
(11); reduced or limited access to abortion services, including the passage of abortion laws that affect adolescents (e.g., parental consent
or notification laws and mandatory waiting periods)
(12--16); and changes in contraceptive practices, including
increased
use of contraceptives (e.g., condoms and, among young women, long-acting hormonal contraceptive methods that
were introduced in the early 1990s) (17--22).

In this report, the abortion rate for the United States was higher than rates reported for Canada and Western
European countries and lower than rates reported for China, Cuba, the majority of Eastern European countries, and certain
Newly Independent States of the former Soviet Union
(23--25).

As in previous years, the abortion ratio in 2004 varied substantially by age. Although the abortion ratio was
highest for adolescents in 2004, since the mid-1980s, the ratio had gradually declined for those aged <15 and 15--19
years, through 2000, but then increased through 2003, and again declined for 2004 (Figure 3). Other studies also
have indicated a decrease in birth rates for females aged 10--14 and 15--19 years during 1991--2003 and a decrease
in adolescent pregnancy rates during 1990--2000
(26--34). However, abortion rates have not varied equally among
women of all races and ethnicities. Abortion rates are declining more slowly among adolescents who are not enrolled in
school (10,34).

The percentage distribution of abortions by known weeks of gestation has shifted slightly since the late 1970s.
From 1992 (when detailed data on early abortions were first available) through 2002, data have indicated steady increases
in procedures performed at <6 weeks' gestation, with a minimal decrease in 2003 but another increase in 2004.
Decreases occurred in the percentage of abortions performed at 8 and 9--10 weeks, and at 11--12 weeks' gestation through
2002, with a minimal increase at 11--12 weeks in 2003, but further decreases in all these groups for 2004. The
increase in the percentage of abortions performed at
<6 weeks' gestation might be related to an increase in the availability of
early abortion services since 1992 and an increase in medical and surgical procedures that can be performed early in
gestation (35,36). Abortions performed early in pregnancy are associated with lower risks for mortality and morbidity
(37,38). The proportions of abortions performed later in pregnancy
(>13 weeks) have varied minimally since 1992.
The gestational age at which an abortion is obtained can be influenced by multiple factors in addition to those for
which surveillance data are available (i.e., age, race, and ethnicity). These additional factors include level of
education, availability and accessibility of abortion services, timing of confirmation of pregnancy, timing of personal
decision-making, timing of prenatal diagnosis, level of fear of discovery of pregnancy, and denial of pregnancy
(39--41).

Since the mid-1990s, two medical regimens (mifepristone and methotrexate, each used in conjunction
with misoprostol) have been tested in clinical trials and used by clinical practitioners to perform early medical
abortions (36,42). CDC surveillance data indicate that approximately 61% of all U.S. abortions are performed at
<8 weeks' gestation, which is similar to the timing of the regimen used for both mifepristone and methotrexate
(38,43). Mifepristone for medical abortion was approved in
September 2000 by the U.S. Food and Drug Administration
(FDA) for distribution and use in the United States. The FDA-approved protocol can be initiated at
<49 days of gestation and requires three office visits by the patient: administration of oral mifepristone, followed 48 hours later by oral
misoprostol in the health-care provider's office, and a follow-up visit in approximately 14 days. Clinical studies of alternative
medical abortion regimens have been performed in multiple countries and are ongoing
(44--52). Second trimester nonsurgical abortion with mifepristone and misoprostol or misoprostol alone also have been clinically effective
(53,54).

In 1997, the U.S. ITOP standard report published by NCHS and used by providers for abortion reporting to
state health departments was revised to include a category for "medical (nonsurgical)" procedures
(55). Medical abortion procedures have been included in this report since then as a separate category. CDC will continue to monitor
early medical procedures and to report on the number of these procedures (Table 8).

The percentage of abortions known to be performed by curettage increased from 88% in 1973 to
>96% during 1980--2001 and then decreased to 89% in 2004
(Table 1), and the percentage of abortions performed by
intrauterine instillation declined sharply, from 10% in 1973 to <1% since 1989. The increase in use of curettage at
>13 weeks probably is attributable to the lower risk for complications associated with the procedure
(56,57). The percentage of abortions performed by curettage at
>13 weeks' gestation (D&E) increased from 31% in 1974 (the first year for
which these data were available) to 97% in 2004, and the percentage of abortions performed by intrauterine instillation at
>13 weeks' gestation decreased from 57% to 0.5%; the percentage of medical abortions increased from 1.0% in 2000
to 9.3% in 2004 (Table 18) (58,59).

The proportion differential of the abortion ratio for black women and that for white women increased from 2.0
in 1989 (the first year for which black and other races were reported separately) to 2.9 in 2004
(60). In addition, the
abortion rate for black women has been approximately three times as high as that for white women (range:
2.6--3.1) since 1991 (the first year for which rates by race were published)
(61). These rates by race are substantially lower
than rates previously published by NCHS (33) and indicate that the reporting areas for the 2004 report might not
be representative of the U.S. black female population of reproductive age. The lack of data from California in this
report skews the rates. Abortion patterns among white and
Hispanic women should be considered with the understanding
that a substantial majority of Hispanic women report themselves as white
(3,26). Therefore, data for certain white
women represent white women of Hispanic ethnicity.

In 2004, a total of 38 states, DC, and NYC reported Hispanic ethnicity of women who obtained abortions.
Because of concerns regarding the completeness of such data (>15% unknown data) in certain states, in 2004, data from only
25 states, DC, and NYC were used to determine the number and percentage of abortions obtained by women of
Hispanic ethnicity. These geographic areas represent approximately 46% of reproductive-age Hispanic women in the
United States for 2004 and approximately 50% of U.S. Hispanic births
(3,26). Therefore, the number of Hispanic women
who obtained abortions was underestimated, and the number, ratio and rate of abortions for Hispanic women in this
report are not generalizable to the overall Hispanic population in the United States. In addition, the value of
making comparisons between the Hispanic and non-Hispanic populations is difficult
because of the diversity in nationality.

Abortion ratios for both Hispanic and non-Hispanic women have declined considerably since 1992 (31% and
27% respectively). As in the past, the abortion rate for Hispanic women was higher (26 per 1,000 women) than the rate
for non-Hispanic women (13 per 1,000). Race- and ethnicity-specific differences in legal induced abortion ratios and
rates might reflect differences among populations in socioeconomic status, access to and use of family planning
and contraceptive services, contraceptive use, and incidence of unintended pregnancies.

NCHS vital statistics reports indicate that fertility and live birth rates were substantially higher for Hispanic
women than for non-Hispanic women for all age groups in 2004
(26). However, because fertility and live birth rates
differ substantially among both the different Hispanic (i.e., Mexican, Puerto Rican, Cuban, and other Hispanic) and
non-Hispanic (white, black, and other) subpopulations, comparisons between Hispanic and non-Hispanic populations are
of limited value (26). Available abortion surveillance data do not permit cross-classification of race by Hispanic ethnicity.

Compared with the early 1970s, the annual number of deaths associated with known legal induced abortion in
the early 2000s has decreased by approximately two thirds (Table 19). In 1972, a total of 24 women died from
causes known to be associated with legal abortions, and
39died as a result of known illegal abortions. At most, two
illegal abortion deaths have occurred in any year since 1979. In 2003, 10 women died from causes known to be
associated with legal induced abortions, and none died as a
result of known illegal induced abortion. National case-fatality rates
for 1998--2003 cannot be calculated because a substantial number of abortions occur in nonreporting states (four states
in 1998 and 1999 and three states in 2000--2003); therefore, the total number of abortions (the denominator)
is unknown.

Of the 10 legal induced abortion-related deaths identified in 2003, four occurred following a medical
(nonsurgical) abortion procedure. Two of these cases have been described previously
(62). This is the first year for which
maternal deaths related to medical abortion procedures have been identified.

Limitations

These data are reported voluntarily and are subject to at least five limitations. First, abortion data are compiled
and reported to CDC by the central health department in the reporting area in which the abortion was performed
rather than the area in which the woman resided. This choice of area inflates the numbers, ratios, and rates of abortions
for areas in which a high proportion of legal abortions are
obtained by out-of-state residents and undercounts procedures
for states with limited abortion services or more stringent legal requirements for obtaining an abortion (causing women
to seek abortions elsewhere). Second, four states (Alaska, California, New Hampshire, and Oklahoma) did not
report abortion data for 1998--1999, three states (Alaska, California, and New Hampshire) did not report data for
2000--2002, and three states (California, New Hampshire, and West Virginia) did not report data for 2003--2004. Data
for California and Oklahoma were estimated before 1998; however, data for nonreporting states have not been
estimated since then. Third, data provided to state or area health departments by providers might be incomplete
(63). Fourth, the overall number, ratio, and rate of abortions are conservative estimates; the total numbers of legal induced
abortions
provided by central health agencies and reported to CDC for 2004 were probably lower than the numbers
actually performed. In addition, the abortion total for 2000 provided to CDC by central health agencies are 20% lower
than that reported for 2000 (the most recent year for which data are available) for the same reporting areas by The
Alan Guttmacher Institute, a private organization that contacts abortion providers directly
(64). A previous report documented a discrepancy of approximately 12%
(65); the reasons for this larger discrepancy are unclear.
Finally, because not all states collected or reported data on all characteristics (e.g., age, race, and the number of weeks'
gestation) of women obtaining a legal induced abortion in 2004, the numbers, rates, and ratios derived in this analysis might
not be representative of all women who obtained abortions.

Public Health Actions

Despite these limitations, findings from ongoing national surveillance of legal induced abortion are useful for at
least five purposes. First, public health agencies use data from abortion surveillance to identify characteristics of women
who are at high risk for unintended pregnancy and use this information to develop interventions to prevent such
pregnancies. Second, ongoing annual surveillance is used to monitor trends in the number, ratio, and rate of abortions in the
United States. Third, statistics regarding the number of pregnancies ending in abortion are used in conjunction with birth
data and fetal death computations to estimate pregnancy rates (e.g., pregnancy rates among adolescents)
(27--31,33). Fourth, abortion and pregnancy rates can be used to evaluate the effectiveness of family planning programs and programs
for preventing unintended pregnancy. Finally, ongoing surveillance provides data for
assessing changes in clinical practice patterns related to abortion (e.g., longitudinal changes in the types of procedures and trends in weeks of gestation at
the time of abortion).

The Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress in 1996 to facilitate
the electronic transfer of health data relating primarily to
insurance coverage and transferability (66). HIPAA
provisions mandate adoption of federal privacy protections for certain individually identifiable health information. The
U.S. Department of Health and Human Services issued the Privacy Rule that became effective on April 14, 2003.
Because the Privacy Rule exempts protected health information required for public health purposes from privacy
protections, covered entities might provide such information without a person's authorization to a public health authority
(e.g., CDC) whose stated purpose is to prevent and control disease. Collection of surveillance data for this report is
exempt from the Privacy Rule. However, the complexity of the rule might result in difficulties in its interpretation
and, therefore, in collecting surveillance data on the part of certain contributing agencies
(66).

Approximately one in five U.S. pregnancies have ended in abortion according to a national sample survey
conducted by AGI during 2001--2002 among women having abortions
(64). Inconsistent method use of the oral
contraceptives (75.9%) or condoms (49.3%) was the most common reason that women became pregnant and obtained abortions
(22). Unintended pregnancy is a pervasive public health problem for all population subgroups and women of reproductive
age (10,61,67).

Although induced abortions usually are performed for women who have unintended pregnancies, which often
occur despite the use of contraception, the approximately 4.6 million women who have had intercourse during the
preceding 3 months but were not using contraception might be the most at risk for unintended pregnancy
(18). Therefore, a reduction in the number of abortions will
require adapting complex strategies aimed at reducing such
pregnancies. Insurance coverage of reversible contraception (e.g., vasectomy and tubal ligation) has increased substantially since
1993 (68), although gaps in coverage remain substantial. Education regarding abstinence and contraceptive use,
including emergency contraception, combined with access to and education regarding safe, effective contraception and
family planning services, might help reduce the incidence of unintended pregnancy and the number of
legal induced abortions in the United States
(69,70).

Acknowledgments

The authors thank Kristi Seed, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health
Promotion, CDC, for her help with the tables.

Office of Management and the Budget. Provisional guidance on the implementation of the 1997 standards for federal data on race and
ethnicity. Washington, DC: Office of Management and Budget; 2000. Available at
http://www.ofm.wa.gov/pop/race/omb.pdf.

Population Division, U.S. Census Bureau. Table 1: annual estimates of the population by sex and five-year age groups for the United States: April
1, 2000 to July 1, 2005 (NC-EST2005-01). Release date: May 10, 2006.

Mosher WD, Martinez GM, Chandra A, Abma JC, Willson SJ. Use of contraception and use of family planning services in the United States:
1982--2002. Advance data from vital and health statistics; no. 350. Hyattsville, MD: US Department of Health and Human
Services, CDC, National Center for Health Statistics; 2004.

World Health Organisation Task Force on Post Ovulatory Methods of Fertility Regulation. Comparison of two doses of mifepristone
in combination with misoprostol for early medical abortion: a randomized trial. Br J Obstet Gynaecol 2000;107:524--30.

Schreiber CA, Creinin MD, Harwood B, Murthy AS. A pilot study of mifepristone and misoprostol administered at the same time for abortion
in women with gestation from 50 to 63 days. Contraception 2005;71:447--50.

 Wyoming reported 12 abortions that occurred in 2004. As a result of the small number and because computing abortion ratios and rates for such
a limited number is not appropriate, Wyoming was not included in this sequence in the text.

§ Ratios for adolescents aged <15 years differ in
Tables 4 and 5 because a different number of areas reported; Table 4 includes 48 reporting areas,
and Table 5 includes 46.

¶ Medical (nonsurgical) abortion procedures involve the administration of a medication or medications to induce abortion.

** After exclusion of 13 areas in which ethnicity data were unknown for >15% of women who obtained an abortion.

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